Information for Patients Vesico-Vaginal Fistula Saint Mary s Hospital/Trafford General Hospiatl Uro-gynaecology Service What is a vesico-vaginal fistula? A vesico-vaginal fistula is an abnormal connection between the bladder (which stores urine) and the vagina. There may be just one opening, there may be more. If you have a fistula, urine will leak from the vagina, and since the vagina is not designed to hold urine you will not be able to control this. How does a fistula develop? A fistula can form after childbirth if the delivery is difficult, after certain kinds of surgery or following radiotherapy. Some people may be born with a fistula. What tests will I need? There are several tests that can be done to check if you have a fistula, where it is and how big it is. 1. Urine specimen You will be asked to give a urine sample which will be tested for signs of infection. If the sample does show these, it will be sent to the laboratory for further testing. This will take 48 hours. If there is an infection your family doctor (GP) will be asked to give you antibiotics. It is important to take all of the antibiotics, even if you do not feel unwell, because if you don t the infection might come back. 2. Vaginal examination An instrument called a speculum may be used to gently open the vagina so that your doctor can look and feel inside to check for leakage. An opening may be seen, but Page 1 of 6 www.mft.nhs.uk
not always, so others tests may be needed. 3. The 3 swab test Three gauze swabs are placed into the vagina using a speculum one at the top, one in the middle, and one at the bottom. A small catheter (hollow tube) is put into the bladder and blue dye is passed through it into the bladder. This will stain the urine in the bladder blue so it can be seen easily should it leak out. The catheter is then removed and you will be asked to walk around for half an hour, but not pass urine. After this time the swabs are carefully removed. If any of the swabs are stained blue then urine has leaked from the bladder into the vagina. This means you have a fistula. This test can also give clues as to where the fistula is depending on whether the top, middle or bottom swab is stained. It will not tell the doctor exactly where the fistula is in the vagina or bladder/urethra or how many openings there are or how big they are, so other tests may be needed. 4. Cystoscopy and examination under anaesthetic (EUA) EUA is an examination under anaesthetic. While you are asleep your doctor will pass a cystoscope (a small telescope) along the urethra and into the bladder. The vagina is also examined. By looking at these tissues the doctor can see exactly where the fistula is, how big it is and check that there is only one fistula so that others are not missed. This allows the doctor to decide which treatment will have the best chance of success. 5. Urodynamics This is a test to check how well your bladder holds urine and empties. Your doctor will tell you if you need this test and also give you a booklet explaining it. 6. X-rays, CT scan and MRI scans It may be necessary to scan your kidneys, ureters (tubes taking urine from the kidneys to the bladder) and bladder before treatment. Your doctor will tell you if this needs to be done. How can a fistula be treated? 1. Catheter Sometimes if the fistula is small and diagnosed early then urine can be kept away from the fistula by a catheter and the fistula may heal by itself. This may take up to 12 weeks. You will be taught how to care for the catheter so that you do not have to stay in hospital. Your local District Nurse will be asked to check on you during this time as it Page 2 of 6 www.mft.nhs.uk
is vital that the catheter does not stop draining. (Your catheter should NEVER be clamped and you should NEVER have a flip flow valve). If the catheter does stop draining, it will need changing immediately so you must contact your District Nurse or Specialist Nurse at the hospital. If you cannot contact either, you should go to your local Emergency Department or the Emergency Gynaecology Unit, taking this booklet with you. If the fistula doesn t heal by itself it can be closed surgically (an operation). 2. Surgery Repairing the fistula can be carried out in different ways: Through the vagina. Through a cut in your tummy. Laparoscopically (keyhole surgery). During the repair the damaged tissue is removed and the fistula is closed with stitches. If your operation is done through the vagina, fat from the labia (the folds of skin surrounding the vagina) may be used to help support the repair (A Martius Flap). In this case you will have stitches in the labia. If the operation is done laparoscopically (keyhole) you will have 3 or 4 cuts on your tummy, one on the left, one on the right, possibly one in the centre and one in your belly button. Each cut will measure 1 cm (less than half an inch). Sometimes an operation will not work and the fistula will open again. If this happens, it can be repaired again. Experience has shown that the first operation has the best chance of closing the fistula. Your doctor will decide which treatment is best for you depending on the size and position of the fistula. After your operation When you return to the ward you will be very sleepy. You will have a drip to give you fluid and pain relieving medicines (either through your drip, by injection or by suppository into your back passage) until you can take them by mouth. You will be given oxygen through a mask or small tubes placed just inside your nose. It is vital that your bladder stays empty so that urine does not build up and cause the fistula to open again. This is why you will have a catheter tube to drain urine from your bladder through the urethra for at least 3 weeks. Every 15 minutes day and night in the initial period the nurse will make sure that the catheter is draining and will measure your urine. Your urine may look blood stained, which is normal at this time. If the catheter stops draining the nurse may have to gently flush the tube to unblock it, but you will not feel this. If this does not work the catheter will need to Page 3 of 6 www.mft.nhs.uk
be removed and another one put in. You might have another catheter draining urine through your tummy. This can be used if the other one blocks. This care is vital to your recovery and may mean your sleep is disturbed. You will have injections into your tummy to thin your blood and prevent blood clots forming in your legs until you go home and medicine to prevent constipation. When you are up and around You will be able to get out of bed as soon as you are comfortable enough and not drowsy. Once you are able to eat and drink you will be encouraged to take 200-300 mls of fluid by mouth, every hour during the daytime. This will help to keep your catheter from blocking and will minimise the risk of urine infection. The nurses will still check your catheter every 15 minutes but you must keep a check on it too. As soon as you feel able: Make sure the tubing is straight and not kinked. Make sure you are not squashing the tubing by lying on it. Make sure you keep the urine bag lower than your bladder but not touching the floor. Check to make sure urine is draining into the bag. If you think it is not, tell the nurse immediately so she can check. If you notice any blood clots in the bag tell the nurse immediately. When your catheter is removed Your doctor will decide when it is time for your catheter to be removed. They may wish you to have a special X-ray test before this to see if the fistula has healed. You will usually be sent home with a catheter in for up to 3 weeks and you will be shown how to care for your catheter before you go home. Your local District Nurses will also be involved in caring for your catheter at home. After 3 weeks you will be followed up by a Specialist Nurse in the Warrell Unit who will carry out another 3 swab test to assess if the fistula has healed. If the fistula has healed then the catheter will be removed. If there is still leakage from the vagina then the catheter will be left in for longer. After any operation there is a risk that you may get an infection. In order to pick this up early the nurses will check your temperature regularly and observe your urine. Page 4 of 6 www.mft.nhs.uk
You can help too by telling your nurse: If you have a nasty smelling vaginal discharge. If you have pain in your groins or lower back. If your urine looks cloudy. If your urine smells different. If you feel feverish. It is important that you do not become constipated after your operation so you should: Try to eat a well-balanced diet with plenty of fruit and vegetables. Include fibre in your diet by eating brown bread and cereal. Drink 1800-2000ml of fluid per day. Tell your nurse if you have not been to the toilet to open your bowels for more than a couple of days or are having to strain. If you have a medical condition that means you cannot eat a high fibre diet please tell your nurse and she will help you with menu choices. When can I go home? Your doctor will decide when you can go home. You are likely to be in hospital for a minimum of 3 days. You will be followed up by the specialist nurse in the Warrell Unit and this appointment will normally be arranged before you go home. Will I have to visit the hospital again? You will be followed up in the Warrell Unit following the procedure. The number of appointments required will depend upon the outcome of the surgery. When can I exercise again? You should not do strenuous exercise for 2 weeks following your operation. After this time gradually reintroduced more vigorous exercise as you feel like it. When can I drive again? You should be fit to drive 2 weeks after your operation. You should check with your motor insurance company in case they have any further restrictions. Page 5 of 6 www.mft.nhs.uk
When can I have sex again? You are advised not to have sex until you have been seen in clinic and the doctor confirms it is okay to do so. Contact us If you have any questions please contact the Warrell Unit Clinical Nurse Specialist on: (0161) 701 6151/6150 Monday - Friday, 8.30 am - 5.30 pm or the Emergency Gynaecology Unit on: (0161) 276 6204 or 6912 (24/7). Page 6 of 6 www.mft.nhs.uk